THE TRANSITION TO SMALL BORE CONNECTORS - Lisa Epp, RDN, LD, CNSC
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THE TRANSITION TO SMALL BORE Lisa Epp, RDN, LD, CNSC
CONNECTORS
1. Describe rationale for small bore connectors.
2. Review the processes than can help with the
transition to small bore connectors.
OBJECTIVES 3. Discuss potential challenges and solutions when
transitioning to small bore connectors.
MISCONNECTIONS WHY?--To prevent misconnections errors have resulted in patient injury and deaths, and they are widely recognized as underreported. Earliest case of misconnection 1972 Cow’s milk intended to be given in the stomach accidently given IV Patient survived the hypersensitivity event but had a coagulopathy 116 other cases of misconnection identified 21 deaths and numerous other serious consequences reported Joint Commission has recognized the serious nature of misconnections
THE TRANSITION First heard about small bore connectors (ENFit®) in 2013 The rollout of these products as been delayed many times however the Global Enteral Device Supplier Association (GEDSA) has announced that legacy feeding tubes will no longer being manufactured after July 1 2021. Likewise, the transition sets and adaptors sold separately from other devices will no longer be manufactured January 1 2022. Estimated 20% of hospitals have made the change Mayo Clinic enterprise converted to small bore connectors in 6/2019 for all feeding tubes and supplies California Law (HB 1867) Effective January 11, 2016 Law will prohibit acute hospitals, acute psychiatric and special hospitals from using an enteral feeding connector that fits into a connection port other than the type for which it was intended.
ISO 80369-3
ENFIT
WHY THE DELAY?
Enteral Standard Polymeric
Nutrition
Hospital Gravity Feeds
Medication Specialty Formulas
Administration
Care Facility Syringe Feeds
Fluid Administration Peptide Based Diet
At Home Pump Feeds
Blenderized Tube
Venting
Feeding
RESEARCH (MAYO AND FDA) For a push mode of feeding, patients will largely be unimpacted after the transition to ENFit ®. For a gravity mode of feeding, some ENFit ® users may need higher- powered blenders and could expect increased feeding times.
STEPS
EDUCATION DOCUMENTATION PUBLICITY HOSPITAL SUPPLY ADDITIONAL
NEEDS HOME NEEDS
EDUCATION Staff Hands-on and written Emphasis on areas that place tubes Patient Update print materials YouTube Video: https://www.youtube.com/watch?v=1qMbxF8nEys
DOCUMENTATION Medical record Tube cards Updating supply codes in home orders
PUBLICITY Local care facilities Group homes Pharmacies Home medical equipment companies
HOSPITAL SUPPLY NEEDS Feeding sets-no change needed Syringes-remove enteral syringes, bring in ENFit® syringes Cleaning brushes (single use) Additional supplies: Medication straws Adaptors Extension sets for low profile tubes New pill crushers
ADDITIONAL HOME NEEDS Medication syringes (now available OTC) https://www.neomedinc.com/neoconnect-at-home/ https://www.udelivermedical.com/store/-c58559166?gclid=EAIaIQobChMIs9- r_Yn38AIVhgqtBh2_jQCXEAAYASAAEgLLbPD_BwE Caps Straws Multi use cleaning brushes Work with home medical equipment providers
SUCCESS Multidisciplinary work group, including supply chain management Make a list of all enteral tubes Obtain ENFit® cross references from the manufacturer Discuss alternatives for devices that aren’t made in ENFit®. Start early, meet often, even after the transition Formulary didn’t change, we still use home blended feedings and viscous formulas.
CHALLENGES
Syringes for liquid medications
Syringes now available OTC
Many medication suppliers have pre-dosed meds drawn-up in ENFit® syringes for distribution in home use; pharmacy
prescription would need to request ENFit® med syringe.
Crushed medication difficult to pull into blunt tip ENFit® syringe
Pour crushed med into a syringe from top
Silent Knight pill crusher
Supply back orders
Venting
Home blended feeding has worked well
Modify venting diet recommendations
Drainage bag no longer being made.
Tubes cracking
If the syringe or feeding bag are overtightened the ENFit® end on the feeding tube can crack.
Per GEDSA It may also happen that leftover formula can cause the connectors to stick firmly tougher and perhaps while
separating the two componentsVENTING DIET-FOR ENFIT® TUBES
VENTING DIET CONTINUED
VENTING Avanos drainage bag being discontinued Potential solution(UK right now) https://www.gbukgroup.com/brands/g buk-enteral/drainage-venting/enteral- drainage-bags/ Potential solution Urinary drainage bags (not ideal)
LEGACY TUBES In light of the Revised ENFit® Connector Conversion Schedule released from the Global Enteral Device Supplier Association (GEDSA), stating by July 1, 2021, “Legacy feeding tubes and cross-application adaptors will no longer be manufactured” and by January 1, 2022, “Transition sets and adaptors sold separately from other devices will no longer be manufactured” by GEDSA members, we would like to share that Applied Medical Technology, Inc. (AMT) will continue to offer a complete line of ENFit® products and a complete line of Legacy devices and accessories, pursuant to FDA regulations.
REFERENCES Guha S, Bouhrira N, Antonino MJ,et al. Impact of Design Changes in Gastrostomy Tube (G- tube) Devices for Patients Who Rely on Home-Based Blenderized Diets for Enteral Nutrition. J Am Coll Nutr. 2019 May-Jun;38(4):311-317. doi: 10.1080/07315724.2018.1509247. Epub 2019 Mar 1. Guha S, Ravi N, Silverstein JS et al. In Vitro Performance Testing of Legacy and ENFit Gastrostomy Tube Devices Under Gravity Flow Conditions. JPEN J Parenter Enteral Nutr. 2018 Nov;42(8):1334-1341. doi: 10.1002/jpen.1159. Epub 2018 Apr 27. Mundi, MS; Epp, L; Duellman, W; Davidson, J, Hurt, R. Impact of Transition to Small Bore Connector for Gravity Enteral Feeding. JPEN J Parenter Enteral Nutr. 2017 Apr 1:148607117703959. doi: 10.1177/0148607117703959. Mundi M, Duellman W, Epp L, et al. Comparison of Syringe Compression Force between ENFit and Legacy Feeding Tubes. JPEN J Parenter Enteral Nutr. 2019 Jan;43(1):107-117 http://stayconnected.org/enteral-enfit/, Accessed 5/25/21
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